Healthcare IT: Savior Or Sinkhole?

Latest RAND report suggests we might be throwing taxpayer dollars away on EHRs and other healthcare IT systems.

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The Office of the National Coordinator for Health IT (ONC) has done an outstanding job of promoting EHR technology through Meaningful Use financial incentives, and it has fostered a spirit of cooperation among IT stakeholders. But ONC sometimes sounds more like a cheerleader than an objective observer on the extent to which modern informatics can transform healthcare.

The jury's still out. A RAND Corporation report in 2005 predicted that the efficiency and safety improvements made possible with health IT could save the U.S. healthcare system $81 billion a year. Since 2005, however, annual health spending has soared from $2 trillion to $2.8 trillion, and quality and efficiency have improved only marginally, despite an increase in health IT adoption, according to researchers Arthur L. Kellerman and Spencer S. Jones in a newly released RAND study published in Health Affairs.

Kellerman, chair of policy analysis at RAND, and Jones, a RAND information scientist and instructor at Harvard Medical School, lay it on the line: "In our view, health IT's failure to quickly deliver on its promise is not due to its lack of potential but to shortcomings in the design and implementation of health IT systems. ... As a result, we believe that the anticipated productivity gains of health IT are being hindered by the sluggish pace of adoption, the reluctance of many clinicians to invest the considerable time and effort required to master difficult-to-use technology, and the failure of many healthcare systems to implement the process changes required to fully realize health IT's potential."

ONC recently boasted about paying out $10.3 billion as of December 2012 to more than 180,000 physicians and hospitals to encourage installation of EHR technology and to bolster its meaningful use in patient care. The new RAND report suggests the program isn't exactly generating meaningful savings.

Like many other observers, the RAND scientists spotlight the lack of interoperability among electronic health record systems as a key barrier. One reason: Providers "have little incentive to acquire or develop interoperable health IT systems," the authors say.

In talking with thought leaders and clinicians, I also get the impression that many healthcare providers would rather forego the incentive checks and even cough up the eventual penalty fees than deal with the aggravation of implementing an EHR system.

Although Kellerman and Jones are right to point to poor design and lack of interoperability as obstacles, the other key to turning EHRs (as well as CPOE and clinical decision support systems) into cost-effective tools is to change the healthcare payment model.

Before healthcare providers small and large will see the need for this technology, they'll have to be forced into a pay-for-performance model that requires a lean, mean operational approach to patient care. Once that financial model is fully in place, clinicians will see the value of a computer-assisted system that picks up needlessly duplicative lab tests, life-threatening drug allergies buried in paper medical records, and the like. Because without such a system, all the excessive tests and adverse patient outcomes will come out of their pay checks.

Cathy Schoen of the Commonwealth Fund, a private foundation attempting to improve the U.S. healthcare system's performance, said it best: "When you pay [providers] differently -- especially emphasizing team care -- information systems become critical as they get used in an efficient and effective way, because people want to avoid duplication. ... They want real-time information on where the patient is and what's going wrong."

Health IT doesn't have to be a sinkhole in which we pour billions of dollars. And in fact many individual provider organizations have proved that it can improve quality of care and lower costs. But as a nation, we still fall woefully short of that goal.

Clinical, patient engagement, and consumer apps promise to re-energize healthcare. Also in the new, all-digital Mobile Power issue of InformationWeek Healthcare: Comparative effectiveness research taps the IT toolbox to compare treatments to determine which ones are most effective. (Free registration required.)

I do not believe it is possible to draw a conclusion from a RAND forecast that is 7 years old. It is a highly questionable approach, and has no scientific merit.

This is once again a demonstration of the 'Luddites in medical practice.' In no other domain, be it biomedical research, finance. law or law enforcement, would anyone be questioning the value of converting from a paper-based system to an electronic record. I just hope that other members of my generation of physicians retires as quickly as possible.

Using an analogy in radiology, it took a decade from the time that DICOM standards of inter-operability were introduced, to adoption of a single interoperable system. Much of that lag can be explained by vendors using their own 'flavor' of DICOM, that could only be used to exchange data to devices and computers on their own systems.

You see a similar phenomenon today - EPIC does not permit health data to be transmitted other EHR systems unless they are EPIC systems.

I would argue that the problem can be attributed to the conservative nature of medical practice, and to vendors that exploit this feature of medical practice for their own benefit.

As an aside- does anyone here know what the fastest growing diagnostic test in the history of medicine might be? It has taken place over the past year, but most clinicians are clueless.

As one who has worked as a health provider CFO and CIO, systems developer/vendor, and health care consultant for over forty years I am not surprised Rand came to its current conclusion. I was really surprised when they said in 2005 we could save $80bill a year.

In all my years of health care experience I have never seen a capital investment in healthcare/medicine actually save dollars when you take a total health system view.

Think about it. Back in the 60G«÷s most lab procedures were done manually. So for better quality and efficiency we invented lab auto analyzers, they could do 2 to 4 chemistry tests all at once. In the 70G«÷s it went up to 20 tests, in the 90G«÷s it went up to 50 and it could be G«ˇdiscreetG«÷ meaning you could pick and choose which test to run. Was all this more efficient? You bet it was. Was it better quality health care? Of course it was, and better quality (and quantity) generated far more information and as such identified many previously hidden patient medical problems. And finding more medical problems meant more health care was needed.

The same can be said for Radiology, first simple Xrays, then CAT scans, PET scans,then NMR, and so on. More efficient, yes, better health care, yes, and more medical problems identified. In short, better diagnoses tools means you will always find more patient problems, which in turn demands more therapies, and more protocols, more specialists, and even more sophisticated tools.Then add to that an aging patient population, more chronic illnesses, and societal issues such as obesity.

What we seem to forget (or ignore) is that health and medical care is not a zero sum game. We have absolutely no idea how many medical problems are out there. The human body is far too complex. Youare not born with with a maintenance manual or a trouble shooting guide. For over a thousand years, using trial and error, we have been trying to G«ˇreverse engineerG«÷ the human body, trying to identify all these possible problems. Yet it seems for every one we do identify we find three more. All these wonderful medical devices have taken us deep into human biology and we still could fill an ocean with what we do not know.

Looking at overall health expenditures and expecting EMRs to reduce them is like believing that the new screw driver set you just bought is all youG«÷ll need to fix your car. EMRs are no more than tool and a relatively simple one at that.Frank PoggioThe Kelzon GroupKelzonGroup.com

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